If you believe the most common sign that you’re having a heart attack is chest pain, you’re not alone. The stereotypical picture of a heart attack includes chest pain and pain in the left arm—but it’s not a very accurate picture. Because although chest pain is quite common, a large number of heart attack victims never experience it. In fact, nearly half of all heart attacks cause no symptoms at all, or symptoms so mild that the victim doesn’t realize what’s happening. These are what are commonly called “silent heart attacks.”

A study published this year in the journal Circulation found that a shocking 45% of all heart attacks are of the “silent” variety. Till now, the official estimate had been that only some 20% to 30% of heart attacks were “silent,” so this study shakes things up a little. The study also found that having a silent heart attack increases your risk of dying from heart disease by threefold.

So how do you know if you’re having a silent heart attack, and what can you do to prevent one? To begin with, we need to clear up common misconceptions about heart attack symptoms.

“Silent” heart attacks might not be completely silent

The difficulty with silent heart attacks is their lack of symptoms, or symptoms that are easily missed. Often people don’t realize they’ve actually had a heart attack till after the fact. This may be weeks, months or even years later. Silent heart attacks are most often discovered during an EKG performed at a later date and for unrelated reasons. But are they really silent?

In some cases, yes. But many seemingly "silent" heart attacks actually do have symptoms—but we don’t realize it. They're simply misinterpreted. This is due in large part to the common belief that heart attacks always include the “classic” symptoms of chest and arm pain.

Nothing could be farther from the truth, especially if you’re a woman. Heart attacks often have subtle symptoms. Many of these are seemingly unrelated to your heart and are easily mistaken for other problems. In fact, one of the most common symptoms of a heart attack is fatigue. Heart attacks may cause gastrointestinal pain that’s misinterpreted as heartburn. They may cause pain in the upper back that’s mistaken for a strained muscle. And many people suffering a heart attack simply have a feeling of general malaise, as if they’re coming down with the flu.

This makes it difficult to decide whether what you’re experiencing is a mild irritation or a major medical emergency. In addition, mild heart attack symptoms in women are still routinely dismissed as “anxiety.”

“Silent” heart attacks are just as deadly the ones that ring alarm bells

A heart attack that causes no symptoms or minimal symptoms is no less dangerous than one that’s more obvious. In fact, it may be worse. When you have a heart attack, a section of heart muscle has its oxygen supply cut off. The muscle begins to die. The affected area then turns into scar tissue as it heals, leaving that part of the heart stiff and non-functional. If too much heart muscle dies, so do you.

Since lack of oxygen is what causes the damage, restoring blood flow—and thus oxygen—to the area is essential. The faster blood flow is restored, the less damage occurs. So prompt treatment is essential. When you have a silent heart attack, you may not get treatment at all and the damage may be even more profound than it would be with a “noisy” heart attack. Having a silent heart attack means you never get the treatment you need. It also means that you’ll miss out on cardiac rehab, which can help minimize the damage and prevent subsequent heart attacks. Because having had one heart attack is the biggest risk factor for having a second—or third one.

Learn to recognize the subtle signs of a heart attack

If you have a truly silent heart attack, there’s not a lot you can do. However, knowing the subtle or atypical signs of a heart attack can go a long way toward recognizing what’s happening. Heart attack symptoms that are often ignored or misinterpreted—especially if you have heart attack risk factors—include:

Unexplained fatigue. We’re all exhausted at some times, but if you’re suddenly fatigued for no reason, or you experience prolonged fatigue with no cause, it may be a sign of a silent heart attack.

Shortness of breath. If you suddenly find yourself short of breath when you haven’t exerted yourself, it may be a heart attack symptom. Likewise, if you’re having difficulty catching your breath during activities that don’t normally leave you breathless, it could be a sign.

Discomfort in your neck, throat, or jaw. This may be pain. It may also be a feeling of numbness, pins-and-needles, or other uncomfortable sensation. If you do have pain, it’s more likely to be a dull ache than a sharp pain.

Heartburn. Discomfort in the chest or upper abdomen may actually be a heart attack rather than heart burn. If you’re not usually prone to heartburn, a sudden attack may be cause for concern.

Pain in your upper back or even shoulder. Heart attack pain is often referred to other areas. It may be felt in your upper back, one or both arms, or even your shoulder. If you’re at risk for a heart attack, don’t dismiss pain in these areas as a strained muscle or an instance of your back needing adjusted.

The bottom line is this: know your body. If you have any heart attack risk factors, and something feels wrong—especially one of the symptoms above—pay attention. It’s better to be safe than sorry, and if you are having a heart attack prompt treatment can literally be the difference between life and death. So “listen” for the symptoms that are easily missed. Don’t let your concerns be dismissed as an anxiety attack. And don’t assume that just because you don’t have chest pain, it’s not a heart attack.

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